Definition and Goals

The International Federation of Manual Medicine³ defines manipulation as “the use of the hands in the patient management process using instructions and maneuvers to maintain maximal, painless movement of the musculoskeletal system in postural balance.” The goal of manipulation or manual medicine is to help maintain optimal body mechanics and to improve motion in restricted areas. Enhancing maximal, pain-free movement in a balanced posture and optimizing function are major goals.^43,69,128 These goals are accomplished by treatments that attempt to restore the mechanical function of a joint and normalize altered reflex patterns,^107,128 as evidenced by optimal range of motion, body symmetry, and tissue texture. The indications for successful use of manual medicine techniques are determined by structural evaluation before and after treatment.^69,103

Manual medicine can involve manipulation of spinal and peripheral joints as well as myofascial tissues (muscles and fascia). The most fundamental use of manual medicine is to relieve motion restriction and improve motion asymmetry. Improved motion and flexibility are helpful in restoring optimal muscle function and ease of motion. A decrease in pain is often associated with restoration of normal motion. Sometimes therapy is directed at reduction of afferent (nociceptive) input to the spinal cord. Endorphin release increases pain threshold and reduces pain severity.^68,87,107

The ultimate goal of manipulation is to improve the function and well-being of the patient. Examples of this include reduction of pain, improved ambulatory ability, and improved efficiency of biomechanical motion. The most basic enabling objective is to improve motion. There are physiologic objectives, such as decreasing nociceptive input, decreasing gamma gain, enhancing lymphatic return, and improving circulation to the tissues.

Manual medicine continues to be widely practiced and is in high demand by patients.⁴⁴ It is estimated that 12 to 17.6 million Americans^130,135 receive manipulations each year, with a high degree of patient satisfaction.²⁶

Overview of Various Types of Manual Medicine

Manual medicine techniques can be classified in different ways. Techniques may be classified as soft tissue technique, articulatory technique, or specific joint mobilization.¹⁰³ The objective to be accomplished can be used as a type of technique, such as movement of fluids. The terms direct and indirect are used to classify technique, with several types of technique in each category. Direct technique means that the practitioner moves the body part(s) in the direction of the restrictive barrier. Indirect technique means the practitioner moves the body part away from the restrictive barrier.

Direct techniques include the following:

Indirect techniques include the following:

Historical Perspective and Practitioners

Manual medicine has regained popularity over the past 30 to 40 years, but its practice dates back to the time of Hippocrates (460 to 377 BC) and Galen (131 to 202 BC).^73,76 Many other physicians (e.g., Sydenham, Hahnemann, Boerhaave, and Shultes) deviated from the traditional disease-oriented form of medicine during the sixteenth and seventeenth centuries,⁷⁶ but manual medicine fell out of favor until the nineteenth century. The pioneers of manual medicine at that time included the “bonesetters” of England—Richard Hutton, Wharton Hood, and Sir Herbert Baker^23,76—followed by Andrew Taylor Still, the founder of osteopathic medicine in 1874,⁶⁹ and Daniel David Palmer, the founder of chiropractic medicine in 1895.^69,76

Still’s philosophy stressed wellness and wholeness of the body.¹¹⁰ Osteopathic principles describe the body as a unit that possesses self-healing mechanisms, and that structure and function are interrelated. All of these principles are incorporated into practice.¹⁶⁴ Manual medicine was and is an integral part of this treatment.

“Traditional” medical professionals have also shown interest in manual medicine. Mennell¹¹⁹ and his son John M. Mennell,¹¹⁹ as well as Edgar and James Cyriax,³⁷ have espoused the use of joint manipulation within the British medical community. Beginning in the 1940s, James Cyriax,³⁷ a British orthopedic surgeon, published several works related to manipulation, incorporating massage, traction, and injections. Travell’s use of manual techniques for examination purposes has been widely accepted.¹⁵⁸ Today, the Fédé ration Internationale de Mé decine Manuelle represents manual medicine practitioners throughout the world.

Barrier Concept

The barrier concept recognizes limitation of motion of a normal joint in which asymmetric motion is present. Motion is relatively free in one direction, with loss of some motion in the other direction. Motion loss occurs within the normal range of motion for that joint (Figure 19-1).

Figure 19-1 A model of somatic dysfunction. The first three panels depict production of somatic dysfunction from a mechanical cause. The last three panels depict treatment positions using thrust technique, isometric muscle energy technique, and indirect balancing. A, A normal joint is positioned in the center, with free motion available in either direction. The shaded area at either end depicts the end of permitted motion. The outside line is termed the anatomic barrier. If joint motion goes beyond this point, structural damage will occur. The Glossary of Osteopathic Terminology describes the anatomic barrier as the end point of passive motion, and the physiologic barrier as the end point of active motion. B, This panel, injury, shows a force moving the center of the joint to the right. C, The third panel, somatic dysfunction, shows the effect of the injury. The neutral point is now positioned to the right. The muscle on the right is contracted and shortened; the muscle on the left is stretched (strained). Motion to the right is freer; motion to the left exhibits bind or restriction. This is asymmetric motion, which is typical of spinal somatic dysfunction. There is restriction of motion to the left, so that the range of motion is impaired. The end point of this restriction of motion to the left is termed the restrictive barrier. Think of the barrier as a series of restrainers that are preventing motion to the left, as contrasted to a brick wall preventing motion. The short, tight muscle on the right prevents full motion to the left. The last three panels show treatment position. D, Thrust technique (impulse, high velocity, low amplitude) is a direct technique. The barrier is engaged by moving the joint to the left. The final corrective force is a practitioner force. E, Direct isometric muscle energy technique looks very similar on the panel. The barrier is engaged by moving the joint to the left. The physician holds and asks the patient to contract against the holding force. The shortened, contracted muscle is the one that is contracting. F, Indirect balancing involves moving the joint to the right, away from the restrictive barrier. The tension should be balanced on both sides. Final corrective force is a release by inherent forces.

The barrier concept implies that something is preventing a full range of motion of a joint. The term pathologic barrier was initially used to describe that point where normal motion is limited. The current term used is restrictive barrier, which means there is no organic pathology that might be seen under the microscope; these are functional restrictions. The motion restriction associated with somatic dysfunction occurs within the normal range of motion of the joint. The new neutral position has shifted in the direction of less restricted motion. This gives rise to positional asymmetry. The lay terms “out” or “out of place” are often used to describe this positional asymmetry. Manipulation is designed to restore normal motion. Manipulation does not put the joint back in place. If a joint is dislocated, this is not somatic dysfunction. Dislocation involves movement beyond the anatomic barrier and involves associated tissue damage.

Normal and Abnormal Coupled Spinal Motion

Motion of the spine follows principles of spinal motion often attributed to Harrison H. Fryette.⁵⁷ Flexion (forward bending) and extension (backward bending) are sagittal plane motions and are not coupled. However, rotation and side bending are coupled. The amount of pure rotation or pure side bending of spinal joints is limited. Rotation and side bending occur together in normal spinal joints. Fryette stated that when there is an absence of marked flexion or extension (termed neutral) and side bending is introduced, a group of vertebrae rotate into the produced convexity, with maximum rotation at the apex. Rotation and side bending occur to opposite sides when compared with the original starting position. This is sometimes referred to as neutral mechanics or type 1 dysfunction. Nonneutral or type 2 mechanics involve a component of flexion or extension with rotation and side bending to the same side. This is usually single-segment motion, although several segments may be involved. The cervical spine (C2–C7) exhibits rotation and side bending to the same side whether flexed, neutral, or extended.

Some atypical joints (occiput, atlas, and sacrum) do not have an intervertebral disk. Their motion patterns are dictated by anatomy. The major motions of the occiput are flexion and extension. Rotation and side bending occur to opposite sides because of the anatomic construction of the joint. The major motion of the atlas is rotation. The atlas rotates around the dens (odontoid process). Half the rotation of the cervical spine occurs at the atlas. Flexion and extension occur but are not involved in motion restriction of the atlas. The atlas does not side bend as it rotates. Actually, both sides of the atlas translate inferiorly during rotation, but side bending does not occur. Trauma can produce atypical motion patterns.

Nomenclature

Physiologic Rationale for Manual Therapies

Indications and Goals of Treatment

Somatic dysfunction is the indication for manual medicine and is diagnosed by palpatory examination. If manual medicine is being considered as a treatment option, there is an overriding question: is there a significant musculoskeletal component to the patient’s problem(s)?

Somatic dysfunction can coexist with “orthopedic disease” (e.g., osteoarthritis or disk disease).⁶³ Manual medicine treatment helps the somatic dysfunction and helps the patient, but the underlying orthopedic disease process will remain. Other confounding factors are causes for the somatic dysfunction. The patient might have an anatomic short leg, which will continue to maintain sacroiliac and low back dysfunction. Certain activities might be too stressful for the musculoskeletal system. In a controlled study of low back pain, it is impossible to control for these confounding factors.

Examination and Diagnosis

An examination is a process of data gathering. Subjective data can be obtained by taking a history. Patient complaints are elicited. Sometimes complaints or concerns are held back by the patient. The practitioner should be aware of these possibilities and attempt to elicit an accurate history. Pain, discomfort, or functional loss is a frequent complaint.

Physical examination includes acquiring a sufficient physical examination database to enable appropriate diagnosis and treatment. Patients in the emergency department routinely undergo examination of the head, eyes, ears, nose, and throat (HEENT), heart, lungs, and abdomen. The musculoskeletal examination goes beyond looking for problems in a system. The practitioner should look for clues about the health status and function of the patient. Is there a somatic component(s) to the patient’s problem(s)? The musculoskeletal screening examination looks at gait, posture, and symmetry or asymmetry. This is ordinarily done with the patient standing. A standardized 12 step biomechanical screening examination may be done,⁶⁹ or the screening examination may be nonstandard, using a systematic approach to evaluate all body regions. This examination can be integrated into a comprehensive physical examination.

Experienced physicians often raise questions, and the examination is tailored to finding answers to the questions. Students ordinarily follow a standardized process when doing an examination. For efficiency the patient should be examined in multiple positions: standing, seated, supine, and prone. To conserve time and enhance efficiency, all tests should be completed with the patient in one position before moving the patient to the next position. The mnemonic for a musculoskeletal examination is TART: T, tenderness or sensitivity; A, asymmetry (look); R, restriction of motion (move); T, tissue texture abnormality (feel). The diagnosis of somatic dysfunction is based on a palpatory examination using TART.

Palpation for Tissue Texture Abnormality

Tissue texture abnormality is palpable evidence of physiologic dysfunction. The approach to palpation is to compare right versus left and above versus below. When evaluating a single area without comparing with adjacent areas, it is difficult to come to a meaningful conclusion. Palpation is done in layers, projecting your sense of touch to the depth required.

Acute tissue texture change can be described and remembered by thinking of acute inflammation and the four cardinal signs: red, puffy, painful or tender, and warm. With acute tissue texture changes, sweating is increased and the skin is usually moist (increased sympathetic tone). Chronic tissue texture abnormality is associated with thin, dry, atrophic skin that is cool. The palpatory quality is firm or fibrotic. Motion testing reveals motion loss.

Paraspinal viscerosomatic reflexes have palpatory qualities that are characteristic and allow the experienced clinician to conclude that these changes are due to visceral disturbances. The maximum intensity of the findings is reported to be at the costotransverse and rib angle areas. The greatest number of findings is in the skin and subcutaneous tissue. Kimberly¹⁰³ described these findings as “minimal motion loss lesions.” Chronic viscerosomatic findings take on the characteristics of any chronic somatic dysfunction. Clinically, findings present as an acute exacerbation of a chronic problem, with the superficial puffiness of acute change and the motion restriction of chronic somatic dysfunction. In the interscapular area, failure to move the scapula laterally to allow adequate palpation of the rib angles will result in failure to detect musculoskeletal findings.

Palpating for tissue texture abnormalities can be an accurate and efficient method of identifying problem areas in the musculoskeletal system that require further examination.

Motion Testing

There are multiple methods for motion testing. Because manipulative treatment has as its immediate objective the improvement of motion, motion testing skills and treatment skills become intertwined. Norman J. Larson, DO, stated, “Your ability to treat is directly proportional to your ability to palpate” (N.J. Larson, personal communication).

Types of motion testing include the following:

Figure 19-2 Motion testing or articulatory treatment of the thoracic spine. The patient is seated, and the practitioner stands behind the patient. The practitioner’s left arm is draped over the patient’s shoulder girdles. This enables the practitioner to introduce forces from above: rotation, side bending, lateral translation, and flexion-extension. The practitioner’s other hand contacts the right side of the thoracic spine. This position is useful for motion evaluation with the patient seated. Articulatory treatment involving left rotation can be done with a combination of force with both the practitioner’s arms or hands.

The muscle energy type of motion testing looks for the most posterior transverse process. Place the palpating fingers on the transverse process area of both sides of the segment to be tested. Instruct the patient to flex and extend. For example, assume T3 is extended, rotated, and side bent right. When T3 is flexed (this is the barrier), the muscle on the right side “balls up” under the palpating finger, and the right transverse process becomes more posterior. When T3 is extended, the findings on either side are decreased. The concept demonstrated is that positional asymmetry is increased when the barrier is engaged.

Using the same example of T3 extended, rotated, and side bent right, flex T3 by flexing the head and neck. Attempt to rotate right and left. Left rotation will be very restricted. Extend T3 and again rotate. Left rotation will be much freer. This confirms that the barrier is flexion, and the dysfunction is extended.

Functional Technique Assessment

The tissues on either side of the dysfunction are palpated for tension with the joint close to the midline and not close to the barriers. Tension is evaluated in the three cardinal planes, three translations, and respiration.^19,93 The position for indirect treatment involves equal tension on both sides.

Assessment of Fascia

Fascia has unique features that include the formation of sheets with multidirectional fibers giving it tensile strength, and sheets with nonlinear motion that allow for shortening and elongating, thus accounting for its flexibility and pliability. In contrast, there is little or no motion in scar tissue. Fascia is three-dimensional and can form sleeves to compartmentalize, act as cables, or form diaphragms. All these properties must be considered when assessing fascia.

Assessment of fascia starts with placement of the hands to perceive the combined vector force in the tissue.⁴⁵ Hand placement varies depending on the area to be assessed and treated. Assessment of an extremity would start with hand placement proximal and distal to the area. An example of this would be the assessment of the forearm. One hand grasps the patient’s hand and the other hand grasps the proximal forearm near the elbow.

In the assessment of a three-dimensional region such as the chest cage, the hands will start with one anterior and the other posterior on the thorax. The hands should be placed in such a manner that they are 180 degrees to one another. Assessment of a large area, such as the thoracolumbar fascia, might begin with the hands placed in the same direction, on either side of the spine, adjacent to each other.

Once the hands are placed, the fascia must be “entered” by adding tension to the area to engage the viscoelastic property of fascia. The viscoelastic property allows fascia to deform. With tension in place, the practitioner can now “read” the tissue and simultaneously assess and treat. The practitioner can move the fascia to a tightened position by combining multiple motion vectors (clockwise-counterclockwise rotation, anterior-posterior motion, cephalad-caudad motion, pronation-supination) as in a direct release, or follow the combined vector to a point of balance as in an indirect release. Examination of the fascia and myofascial structures may include looking for special “points” or “triggers.” These include counterstrain tender points, the myofascial triggers of Simon and Travell, and acupuncture points.

Types of Technique

Direct Techniques

Soft Tissue Technique

The purpose of soft tissue technique is to relax muscles and fascia. There are an infinite number of modifications of soft tissue technique. Usually they involve lateral force to stretch the muscle, direct longitudinal stretching, or careful kneading. Sensitive hands and experience are necessary to assess the response of the tissues to the treatment. Apply forces slowly and release slowly. Do not allow tissues to snap back quickly or spasm might occur. Do not allow your fingers to slide over the skin. Avoid excess force per unit area; instead, spread the forces out. Avoid direct pressure over bony prominences. Soft tissue technique can be the primary approach. It can be used to prepare an area for specific mobilization. It can be used to facilitate movement of fluids. It can reduce or modify pain. This is similar to massage, but there is a different end point of the treatment. The focus here is on moving tissue rather than relaxing muscles.

Articulatory Treatment

This procedure moves a joint back and forth repeatedly to increase freedom of range of motion. Articulatory treatment may be classified as a low-velocity, high-amplitude approach. Sometimes articulatory treatment is a form of soft tissue treatment in which the only way to access deep muscles is to move origin and insertion (see Figure 19-2). Articulatory treatment is very useful for stiff joints and for older patients. It might be the only form of treatment applicable for some patients. There are many modifications to articulatory technique.

Mobilization With Impulse (Thrust; High Velocity, Low Amplitude)

Thrust technique is often considered synonymous with manipulation. In Europe, thrust techniques are reserved for the physician, whereas other techniques are termed mobilization. Given an expansion of the various forms of techniques other than thrust, these techniques are sometimes termed soft manipulation. Thrust techniques are applicable for restriction of motion in joints. Thrust technique is often the quickest form of addressing restriction of joint motion. An audible pop can occur with application of the technique. The noise has no effect on treatment outcome. To assess the effectiveness of treatment, reevaluation is required.

A diagnosis of motion restriction is essential before application of thrust technique, and this diagnosis should incorporate the three planes of motion: flexion-extension, rotation, and side bending. The first principle of thrust technique is to engage the barrier. With an accurate diagnosis, engaging the barrier is specific. The barrier must feel solid, not rubbery. A thrust should not be applied if the barrier does not feel solid. Instead of addressing the restriction of motion of the joint, the force is dissipated by muscles and fascia. The thrust must be low amplitude, meaning a very short distance. The thrust should be high velocity (Figures 19-3 through 19-5). There is no place for high-velocity, high-amplitude technique.

Figure 19-3 Treatment of cervical spine C2–C7. In this example, the diagnosis is C4 flexed, rotated, and side bent right. The right lateral mass of C4 is contacted with the index finger. An extension break at C4–C5 keeps force localized to the segment. The force is directed toward the patient’s eye. This force is rotation left, side bending left, following the principles of physiologic motion of the cervical spine. Additionally, the plane of the facets angles up toward the eye. The force follows the plane of the facets, rather than jamming the facets, which would occur if proper side bending was not considered.

Figure 19-4 Treatment of thoracic somatic dysfunction, patient supine. There are multiple variations of this technique, sometimes referred to as the “Kirksville krunch.” It is used for thoracic type 1 and type 2 dysfunctions, as well as ribs. The technique pictured involves T7 flexed, rotated, and side bent left. The practitioner stands on the left side of the supine patient. The patient’s arms are folded across the chest or, as in this demonstration, the patient’s hands are placed behind the neck with fingers clasped together and elbows approximated. The practitioner’s fulcrum hand is placed over T8 right (segment below, side opposite) (A). The patient’s torso is rolled back, and the corrective force is applied through the patient’s arms (B). Note: many practitioners place the fulcrum directly over the posterior transverse process or the posterior rib. If the thoracic dysfunction is extended, care must be given to maintain a flexed position at the site of the somatic dysfunction. The fulcrum tends to produce extension.

Figure 19-5 Treatment of lumbar somatic dysfunction, patient on side. The literature contains multiple approaches for side lumbar techniques. The technique being demonstrated follows principles of physiologic motion of the spine. The dysfunction is L2 flexed, rotated, and side bent right. The posterior transverse process is placed down (right side down). The patient’s torso is perpendicular to the table. The patient’s hips and knees are flexed, the upper leg flexed more. Extension at L2 is obtained from above. Side bending is maintained by stretching out the right side. Rotation from below is obtained by contacting the patient’s iliac crest, rotating toward the operator, and applying side bending by pushing cephalad. Rotation from above is obtained by pushing the shoulder posteriorly. Additional localization is obtained by having the patient look toward the ceiling. The final corrective force on the iliac crest emphasizes side bending toward the patient’s head; rotation is automatic.

The tissues should be prepared for thrusting technique. Soft tissue treatment is often a precursor to thrust technique. If the tissues are not properly prepared, it is more difficult to engage the barrier and more force is used. The dissipation of excess force can cause iatrogenic problems. The patient must be relaxed. There is no substitute for skilled hands that allow the patient to relax. Often the thrust is given during exhalation, because the tissues are more relaxed at this time. The final activating force is operator force.

Muscle Energy: Direct Isometric Types

Muscle energy technique^65,123 was introduced by Fred Mitchell, Sr.¹²¹ Muscle energy technique involves the patient voluntarily moving the body as specifically directed by the practitioner. This directed patient action is from a precisely controlled position against a defined resistance by the practitioner. The initial classification of muscle energy techniques was based on whether the force was equal (isometric), greater (isotonic), or less (isolytic) than the patient force. Most muscle energy techniques used by physicians are direct isometric techniques. This technique has been used extensively by therapists and is often referred to as contract relax technique.

Muscle energy technique requires a specific diagnosis. The first step is moving the dysfunctional component into the restrictive barrier. Fred Mitchell, Jr,¹²² emphasizes that the practitioner moves the dysfunctional component to the “feather edge” of the barrier. The practitioner holds this position and instructs the patient to contract against the holding force. The patient controls the amount of force, so injury is not likely. Additionally, the manner in which the practitioner holds the patient position suggests the amount of force. A heavy-handed vice grip will suggest more force than a lighter touch. The muscle contraction is held for 3 to 5 seconds. Then there is a period of relaxation, sometimes termed postisometric relaxation. The practitioner then reengages a new barrier, and the process is repeated several times. If there is no further increase in the range of motion, it is time to stop. Three repetitions are the usual number, followed by reassessment.

Most direct isometric muscle energy techniques involve the patient actively contracting the shortened (sometimes referred to as the “sick”) muscle. The usual mistakes in using muscle energy technique are failure to properly engage the barrier, application of too much force, or not allowing enough time for postisometric relaxation. Although engaging the barrier involves three planes of motion, the patient contraction may be in one, two, or three planes. Often the patient contraction will be a flexion or extension. In muscle energy technique the final activating force is a patient muscle contraction.

Direct Myofascial Release

The goal of myofascial technique is to identify tissue restriction and to remove the restriction. This requires sensing arms and hands. Direct myofascial technique involves loading the myofascial tissues (stretch), holding the tissues in position, and waiting for release. Release is by inherent forces. When collagen is stretched, the viscoelastic properties of collagen allow the tissues to slowly stretch. The term creep is applied to this phenomenon. When release occurs, there is additional lengthening of the tissues without an increase of force being applied. This phenomenon takes several seconds. This release might be likened to an ice cube melting. The release is perceived by the practitioner treating the patient. Reevaluation of the patient reveals a decrease of the restriction being treated, with increased freedom of range of motion.

Indirect Techniques

Strain-Counterstrain

Counterstrain is a type of manipulative treatment that uses spontaneous release by positioning, and uses tender points serving as a monitor to achieve the proper position. Lawrence Jones, DO,⁹⁴ developed this method of treatment. Counterstrain is classified as an indirect technique. The objective is to relieve painful dysfunction through a reduction of inappropriate afferent proprioception activity. Referring to Figure 19-1, the shortened muscle remains shortened because of inappropriate proprioceptive activity. Tender points are located in the muscle belly, tendon (usually at or near the bony attachment of the tendon), or dermatome of the shortened muscle. Treatment position further shortens the short muscle, as a “counterstrain” is applied to the originally strained muscle on the other side. The neurophysiologic mechanism is based on the fact that shortening the muscle quiets the muscle and breaks into the inappropriate strain reflex.

Tender points are related to specific dysfunctions. The practitioner must know where to look for these specific points.⁹⁵ For example, if the patient has a dysfunction at L3 that is flexed, rotated, and side bent left, an anterior lumbar tender point is located in the abdominal wall in the vicinity of the anterior inferior iliac spine. The use of counterstrain requires a structural evaluation and assessment for tender points. Tender points are tissue areas that are tender to palpation. They are sometimes described as “pealike” areas of tension. The common denominator is the tissue change and tenderness.

Treatment involves identifying the tender point, maintaining a palpating finger on the tender point, and placing the patient in a position so that tenderness in this point is eliminated or reduced significantly. This position is in a pain-free direction of ease. Also, the position places the patient in the original position of injury. Counterstrain is not a form of acupressure. The monitoring finger continues to palpate and assess the point, but pressure is not applied. The amount of time that the treatment position is held is 90 seconds, 120 seconds for ribs. It is essential that the patient be slowly returned from the treatment position to the starting point. The patient should remain passive during the entire process. After return, the tender point is reassessed. If the physician’s palpating finger stays on the tender point, and tenderness is now absent, both practitioner and patient know that a change was made (Figure 19-6).

Figure 19-6 Hamstring release technique, counterstrain. The technique follows the principles of counterstrain without looking for a tender point. The patient is prone, and the monitoring fingers contact the hamstring tendons close to the knee. The knee is flexed until the rectus femoris muscle is loaded, preventing increased flexion of the knee. The hamstrings are unloaded, the rectus femoris is loaded. Hold and wait for release, as monitored by contact over the hamstring tendons.

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